1. Renal trauma is the most common type of urinary trauma, usually caused by blunt trauma. It is graded from I to V based on severity, with grade I being minor injuries like contusions that often heal spontaneously. 2. Ureteral injuries are usually caused by external penetrating trauma or surgical trauma. Symptoms include flank pain and hematuria. Bladder trauma is often due to blunt abdominal trauma and is associated with pelvic fractures. Hematuria is a hallmark sign. 3. Urethral injuries can be anterior or posterior. Posterior injuries are often due to pelvic fractures and present with the triad of blood at the meatus, inability to urinate, and

1. UROLOGIC TRAUMA
Ferdinan BS (130100165)
Kamilah AS (130100051)
Shafura HN (130100137)
Yoseph HAW (130100040)
Firdaus LP (130100283)
FAKULTAS KEDOKTERAN
UNIVERSITAS SUMATERA UTARA
MEDAN
2018

2.  Renal trauma
 Ureteral injury
 Bladder injury
 Urethral injury

3. RENAL TRAUMA
 Most common type of urinary trauma
 Etiology :
- 80-90%  blunt trauma (falls from height,
motor vehicle)
- 10 – 20%  penetrating trauma (gunshot
& stab wound)
 children (< 1 yrs) more prone to renal injury
due to relative large size of kidney, scant
perirenal fat, underdeveloped Gerota’s
fascia

4. RENAL TRAUMA
 Majority cases are grade 1
 Such heal spontaneously without adverse
sequele and require no imaging or active
treatment
 MUST be suspected if
 Significant flank ecchymosis / hematuria
 Lower (T8-12) rib fractures
 Sudden decelaration / Fall from height.
 Penetrating abdominal or flank injury
 Hematuria: degree of hematuria does not
correlate with the of severity of the trauma

5. Renal trauma :
Clinical findings
 Symptoms : evidence of abdominal trauma,
pain, hematuria
 Signs : shocks, ecchymosis
 Lab findings : microscopis or gross hematuria

6. Renal trauma :
Classification of Injury
 5 Classes of Renal Injury :
Organ Injury Scaling
Committee
Moore et al. Organ Injury Scaling: Sleen, Liver and Kidney,
The Journal of Trauma, 29: 1664; 1989.

7. Renal Trauma
 Grade 1,2 : minor trauma
 Grade 3,4,5 : major trauma

8. Grade I
 Contusion
 Hematuria (micro or
gross)
 Urologic studies N
 Hematoma
 Subcapsular
 Non expanding
 Parenchyma N

9. Grade II
 Hematoma
 Perirenal
 Nonexpanding
 Laceration
 < 1.0 cm
 Renal cortex only
 No urinary
extravasation

10. Grade III
 Laceration
 > 1.0 cm
 Renal cortex only
 No urinary
extravasation
 Intact collecting
system

11. Grade IV
 Laceration
 Renal cortex
 Renal medulla
 Collecting system
 Vascular
 Main renal
artery/vein injury
with contained
hemorrage.

12. Grade V
 Completely
shattered kidney.
 Avulsion of renal
hilum (pedicule)
which
devascularizes
kidney.
Kennon et al. Radiographic assessment of renal trauma: our 15-year
experience. The Journal of Trauma, 154: 353-355; August 1995.

13. Renal trauma :
Complication
 Depent on the grade and the method of
management
 Usually occur within 1 mo of injury
 Early complication :
- prolonged urinary extravasation
- urinoma
- shock from massive blood loss
- renal infarction
- abscess formation

14. Renal trauma :
Complication
 Late complication :
- delayed bleeding, av fistulas, abscess,
urinary fistula, hydronephrosis
- renal vascular hypertension
- perinephric fibrosis
- 3 – 6 mo later  IVU or CT to evaluate
delayed hydronephrosis or renal atrophy

15. Renal trauma :
Management
 Prompt treatment of shock and hemorrhage,
complete resuscitation and evaluation of
associated injuries
 Surgical methods of renal exploration &
reconstruction
 Non operative & conservative  properly
staged and selected renal injuries can be
succesfully managed conservatively

16. Renal trauma :
Management
 Strict bed rest until the urine visibly
clears
 Close monitoring of vital signs
 Hematocrit, blood drawn every 6 hours
until stable
 Broad-spectrum AB
 Transfusion

17. URETERAL INJURY
 Mechanism :
1. External trauma : penetrating trauma (rare)
high velocity missiles
2.Surgical trauma : Hysterectomy surgery
(paling sering)

18. URETERAL INJURY :
Sign & symptom
 Symptoms : fever, flank and lower quadrant
pain, if bilateral  anuria
 Signs : acute hydronephrosis, sign &
symptoms of acute peritonitis may be (+)
 Imaging : IVU, RPG, CT

19. BLADDER TRAUMA
 86% due to blunt abdominal trauma
 90% assoc with pelvic fx
 60% extraperitoneal, 30% intraperitoneal,
10 – 12% combined injuries
 Mechanism of injury :
- intraperitoneal
- extraperitoneal

20. BLADDER TRAUMA :
Sign & symptom
 Hematuria is the hallmark
 Bladder dome = weakest point
 Pelvic or lower abdominal pain
 Inability to urinate
 Imaging :
- cystography
- CT cystography

21. Extraperitoneal Bladder Rupture:

22. Intraperitoneal: Dome is weakest

23. BLADDER TRAUMA :
Management
 Extraperitoneal – foley drainage X 14 days,
Antibiotics, let it seal.
 Intra-peritoneal – surgical repair.
 Intraperitoneal urine is an irritant.
 Ileus, sepsis, peritonitis.

24. URETHRAL TRAUMA
 Relatively uncommon
 Divided into anterior & posterior injuries
 Vast majority are due to blunt trauma
 Posterior injuries are due to pelvic fx
 Anterior injuries are due to straddle type inj
 The management goal is to minimize the
chances for debilitating complications of
incontinence, impotence & stricture

25. Urethral Trauma
 According to location
 Anterior urethra:
bulbous & pendulous
 Posterior urethra:
membrano - prostatic
Prostatic
Membranous
Bulbous
Pendulous

26. Posterior urethral injuries
 73% is complete, 27% partial
 Rare in women
 Mechanism: pelvic fracture
 Triad:
 “Blood at the meatus”
 Inability to urinate
 Full bladder

27. Posterior urethral injuries :
signs & symptoms
 Blood at meatus
 Gross hematuria
 Perineal ecchymosis or hematoma (GU
diaphragm is disrupted)
 Scrotal or penile hematoma
 Difficulty passing a foley cath
 Distended bladder and inability to void
 Non palpable prostate
 Classical triad

28. Posterior Urethral rupture
From McAnich JW. In Tanagho EA, McAninch JW, editors: Smith’s general urology, ed 14, Norwalk, Conn, 1995, Appleton & Lange.

29. Posterior Urethral Injury :
Management
 ““Do not attempt to pass a catheter”
 Unstable patient: suprapubic tube
 Stable patient: early or late endoscopic
realignment

Simultaneous cystoscopy and urethroscopy

“Cut to the light”
 Open repair
 Complications: ED, incontinence

30. Posterior Urethral Injury
Management
 Partial tear
 careful passage of 12-14 Fr. Foley.
 If any resistance  Urology
 Complete tear:
 Urology + suprapubic cath.
 If Foley already there and suspect tear:
 LEAVE FOLEY IN PLACE
 Small tube alongside the foley
 Angiocath 16-gauge
 Modified urethrogram

31. Anterior Urethral Injury
Blunt trauma
 Caused by direct injury to the penis & urethra
 More common than posterior
 If Buck’s fascia intact  blood & urine remain
within the penis  ‘sleeve hematoma’
 If Buck’s fascia disrupted  blood & urine can
spread to the scrotum, abdominal wall,
perineum and thigh
 Extravasation into the perineum  ‘butterfly
sign”

32. Sleeve Hematoma

33. Butterfly Hematoma

34. Anterior Urethral Injury :
Signs & symptoms
 Hystory of direct perineal trauma / strddle
injury
 Blood at meatus (the most important
predictor)
 Perineal and/or scrotal swelling &
ecchymosis or tenderness
 Penile hematoma
 Inability to void
 NO Foley if injury suspected

35. Anterior Urethral Injury :
Classification & Management
 Contusions
if pat can void easily and the urine
relatively clear  no Foley or additional
treatment
 Lacerations
- incomplete  proximal urinary diversion by
suprapubic tube (14 – 21 days)
- complete  high stricture rate  delayed
open surgical repair

36. Anterior Urethral Injury
Penetrating trauma
 Amount of contrast extravasation on RUG
does not correlate with severity of injury
 RUG should be performed for :
- all penetrating wounds to the penis or
perineum
- blood at the penile meatus
- gross hematuria
- a suspected renal injury

37. Anterior Urethral Injury
Penetrating trauma
 Management :
- primary repair for stab wounds & GSW
- stricture rates 80% for urinary diversion
and stenting vs 10 – 12% for primary repair
- surgical manage is conservative
debridement & primary end-to-end
anastomosis

38. wr’10